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AUTISM SPECTRUM DISORDER

Research Suggests Good Nutrition May Manage Symptoms Decades ago, autism spectrum disorder
(ASD), a group of developmental disabilities in which patients have significant
social, communication, and behavioral difficulties, was consid­ered rare, and
the prognosis of those who had it usually wasn’t good. Many individuals were
committed to institutions for the rest of their lives because of their
inability to function in society. But times have changed.

The prevalence of ASD among adults and
children has sky­rocketed over the last several years. Much more research on
the etiology of the disorder and the different ways to treat and manage it has
become available. Today there’s evidence show­ing how nutrition therapy can
play a significant role in manag­ing various symptoms that prevent ASD patients
from living productively.

This continuing professional education
course will define ASD, discuss its prevalence and possible causes based on the
latest research, and evaluate the critical role good nutrition may play in
helping individuals function optimally. Dietitians will learn about the various
nutrition therapies available and be able to apply them to practice.

Defining Autism

The word “autism” comes from the Greek
word autos, mean­ing “self.” It’s been used for about 100 years to
describe a condition in which people can’t engage in social interaction.
Originally, it was thought to be associated with schizophrenia. In 1943, Leo Kanner,
MD, known as the father of child psychia­try for his pioneering work related to
autism, first identified the disorder at The Johns Hopkins University in
Baltimore. Also in the early 1940s, German scientist and pediatrician Hans
Asperger, MD, identified patients with similarly withdrawn behavior, now known
as Asperger’s syndrome.

Today, autism is better defined by the
term “autism spectrum disorder,” which describes a grouping of various
developmental disabilities. Symptoms of ASD usually begin before the age of 3
and continue throughout a person’s life. In some infants, there are early signs
of the disorder, such as not wanting to cuddle, lack of eye contact, or
abnormal responses to touching and affection. Other early signs include the
inability to follow objects visually, not responding to his or her name being
called, and lack of facial expressions, such as smiling. Some children with ASD
develop normally until the age of 1 or 2, then stop learning new skills or lose
the ones they already have learned.

There are three main classifications of
ASD and understand­ing the difference among them will help to better focus
treat­ment. The first classification of ASD is autistic disorder, which is
considered the classic form of autism. Patients usually have significant delays
in language, social skills, and the ability to communicate. Some have unusual
behaviors and interests, and have a measurable intellectual disability.

The second form of autism is
Asperger’s syndrome, usu­ally a milder form of autism. Patients still have
delays in social abilities and communication skills, and have unusual behav­iors
and interests.Many individuals have a specific interest that encompasses much
of their time and thought. People with eg, trains, computers). They usually
don’t have issues with lan­guage skills or intellectual development. In fact,
many are intel­ligent, especially when it comes to their own special interests.
Some experts liken patients with Asperger’s to little professors in their areas
of interest; they can have near genius IQs.

The third form of autism is pervasive
developmental dis­order, not otherwise specified, or atypical autism. These
indi­viduals meet only some of the criteria for classic autism or Asperger’s.
They have fewer, milder symptoms and may experience delays only in the areas of
social skills and communication.

Current ASD
Statistics

The number of children diagnosed with ASD
has increased almost tenfold in the last 40 years.5 Currently, one in every 88
children is diagnosed with ASD.5 When broken down by gender, five times more
males (one in 54) than females (one in 252) are affected.5 These statistics
indicate that ASD affects more than 2 million people in the United States and
more than 10 million worldwide. According to the organization Autism Speaks,
ASD affects more children than diabetes, AIDS, or cancer combined.

The increase in diagnoses may be due in
part to better diag­nostic tools, but many believe environmental toxins and
genet­ics hold better clues to the increase in prevalence, although this hasn’t
been proven.

Link Between ASD
and Environmental Toxins

No specific environmental toxin has been
identified as the cause of autism, but research to determine which chemicals
may be culpable is under way. It’s been proven that a fetus is vulnerable to
environmental chemicals during development. Examples of chemicals that, in the
past, have been shown to harm fetal development include organophosphate insecti­cides6
(eg, chlorpyrifos), mercury exposure, and heavy metals (eg, lead).

It’s a widely held belief that people with
ASD have diffi­culty eliminating toxic chemicals from their body. If this is
the case, exposure to environmental contaminants could play a significant role
in poor neural development or brain func­tion processing. Unfortunately,
because of the short amount of time research has been conducted on the link
between autism and environmental toxins, causality still remains speculative.
However, it continues to appear that genetics, environment, and the interaction
of a child’s physical and psychosocial environment play an interrelated role in
the possible causes and triggers of ASD. Such associations can be seen in the
high incidence of autism in twins and genetic siblings who have the disorder.

Other suspected causes of autism include
advanced parental age, low birth weight, and multiple births. A viral
infection, such as the flu, in the first trimester has been shown to triple the
odds of a child developing ASD, and a bacterial infection, such as a urinary
tract infection, in the second trimester has been found to increase the risk of
ASD by 40%. Recently, researchers examined inflammatory disease as a possible
cause of autism and found that it could possibly contribute to the etiology of
the disorder.

Problem-Eating
Behaviors

While the medical community may not have
identified the exact causes of ASD, much has been learned about the chal­lenges
ASD patients face that often lead to poor diet qual­ity. These include problems
with sensory processing, eating behaviors, and feeding disorders. It’s
estimated that 46% to 89% of patients with ASD experience some kind of
problem-eating behavior. Some feeding difficulties revolve around changes in
routine. For example, patients with ASD may refuse to eat unless they sit in
the same place at the table, eat on the same dishes, use the same tablecloth,
and eat the same foods daily. The slightest change in routine can cause a
tantrum or result in the refusal to eat.

Other issues may occur in the area of
sensory processing. For example, if children with ASD are hypersensitive to
sounds, they may not want to eat in a noisy area or with others engaged in
conversation. If they have visual sensitivities, they may accept foods only of
certain colors. They also may not be able to eat foods that are touching each
other on their plate.

Some children are sensitive to the way
foods feel in their mouth. They may avoid crunchy foods or foods that have a
slick mouthfeel. The way food smells can cause similar reactions, and there are
instances in which children may not recognize certain tastes but can distinguish
between others.

A study by Benetto and colleagues showed
that children with ASD were less able to accurately identify sour or bitter
tastes but could recognize salty and sweet tastes. This study may shed light on
why patients with ASD avoid several types of foods, such as proteins, but will
usually accept foods in the car­bohydrate group.

The best approach to solving
problem-eating behaviors, according to Elizabeth Strickland, MS, RD, LD, author
of the book Eating for Autism: The 10-Step Nutrition Plan to Help Treat Your
Child’s Autism, Asperger’s, or ADHD, is to assemble a “feed­ing team,” a
group of healthcare professionals consisting of a physician, speech language
pathologist, occupational therapist, behavioral therapist, and RD. A dietitian
can evaluate the foods the child agrees to eat for potential dietary
deficiencies. He or she can watch the child and family during meal times to
assess habits that may be hindering food intake. An RD also can screen the
medications the child takes that may have side effects that contribute to
feeding problems.

ASD and Food Additives

Just as problem-eating behaviors can prevent ASD
patients from getting the nutrients they need, so can consistently con­suming
highly refined foods. Since highly refined foods may contain artificial dyes
and preservatives that could be asso­ciated with aggravating behavioral
symptoms in those with ASD, suggesting the family eat natural, whole foods may
be an important treatment intervention.

When discussing dietary recommendations
with ASD patients or their parents or caregivers, also suggest that patients be
screened for nutritional deficiencies that can result from the medications they
take.

Dietitians working with ASD patients can
recommend elimi­nating the following substances from an ASD patient’s diet if
they believe a sensitivity exists:

• Food dyes and artificial colors: These additives have been
linked to hyperactivity, breathing disorders, skin eruptions, and
gastrointestinal symptoms in non-ASD patients. Since many ASD patients already
have these symptoms, eliminating foods that contain these substances may be
helpful to assess a patient’s reaction.

• High-fructose corn syrup: One of the main concerns with
high-fructose corn syrup involves the manufacturing process. Research has found
that mercury, one of the environmental toxins that may be responsible for the
increased prevalence of ASD, is part of the refining process when making
high-fructose corn syrup.7 Removing it from the diet whenever possible may be a
helpful suggestion.

• Artificial flavorings: Monosodium glutamate (MSG), for
example, has been shown to cause headaches, muscle tight­ness, numbness or
tingling, weakness, and flushing in people who are sensitive to it. Because of
these known potential side effects, it may be appropriate for ASD patients to
avoid MSG as a precautionary measure.

• Artificial preservatives: Studies have indicated that
artificial preservatives may cause sensitive individuals to experience
headaches, behavioral/mood changes, or hyper­activity. So removing foods that
contain these substances may be beneficial.

• Artificial sweeteners: Aspartame, acesulfame-K,
neotame, and saccharin have been known to cause headaches, mood changes,
nausea, vomiting, and diarrhea in the general population.

When discussing dietary recommendations
with ASD patients or their parents or caregivers, also suggest that patients be
screened for nutritional deficiencies that can result from the medications they
take. Some medications can affect appetite and cause nausea, vomiting,
constipation, hard stools, diarrhea, esophageal reflux, weight gain or loss,
sedation, drooling, and sometimes dysphagia, all of which can compro­mise
nutritional status. For example, if a child is constipated, he or she may
experience a decrease in appetite. If dysphagia is an issue, he or she may
decrease food intake for fear of choking while swallowing. If medication causes
sedation, the child may not feel the need to eat even though he or she is
hungry.

Supplementation

Another aspect of ASD treatment involves
supplementa­tion with multivitamins, omega-3 fatty acids, vitamins D and B6,
magnesium, and other nutrients. Beginning multiple sup­plements at one time may
impede the ability to determine what’s working or not working in ASD patients.
Therefore, the best strategy may be to start one supplement at a time for
several weeks to determine whether there’s an improvement in symptoms.

If the patient takes one supplement for
several weeks and experiences no improvements in symptoms, it means the
supplement may not be helpful for that particular patient. If improvements are
seen, stopping the supplement for a week or so to determine whether symptoms
return can be a good strat­egy to gauge effectiveness. This process allows ASD
patients to follow the least restrictive regimen possible while identifying
improvements in symptoms.

Multivitamins

Most practitioners who work with ASD
patients agree that a good-quality multivitamin without artificial colors or
flavors can help offset limited dietary preferences and poor nutritional
intake. Finding the right multivitamin will depend on a patient’s tolerance.
Some will swallow a pill, while others will prefer a liquid, gummy, or chewable
form. RDs are in a perfect position to determine what’s acceptable and meets
each patient’s needs.

Omega-3 Fatty Acids

Research has shown that adding omega-3 fatty acid sup­plements
to ASD patients’ diets may provide many benefits.

Omega-3s are critical for brain
development and proper neural function. Multiple studies have shown imbalances
in the ratio of omega-3 to omega-6 fatty acids in the bloodstreams of ASD
patients. Obtaining adequate amounts from food alone may be difficult because
of the limited number of foods they may eat. For example, some children with
ASD won’t eat cold-water fish (eg, salmon, tuna), and some parents won’t add
fish to their children’s diet because they believe it contains mercury that may
exacerbate ASD symptoms. Still, many parents do give their children omega-3
supplements.

Some practitioners recommend 1.5 g/day of
omega-3 fatty acids for most pediatric patient populations. According to
research, children with ASD who take omega-3 supplements have less anxiety and
aggression, decreased hyperactivity and impulsivity, longer attention spans,
and improvement in lan­guage development, reading, and spelling skills. Most
omega-3 supplements are made from fish oil, so it’s impor­tant to ensure
they’re free of mercury. (The label will indicate mercury-free processing.)
Because oils can become rancid, it’s best to use supplements before their
expiration date. Some supplements contain added vitamin E as a preservative to
improve shelf life, while others are bound with dietary calcium to preserve the
oil at room temperature.

If patients complain of stomach upset or
fishy burps but don’t experience this when they eat fish, question the
freshness of the supplements. Patients may need to keep the supplements in the
refrigerator so they stay fresher longer.

Vitamin D

Several studies suggest a direct link
between low vitamin D (25-hydroxyvitamin D) levels and the risk of ASD since
vita­min D regulates the immune system. Research shows that children are at
risk of ASD because of their body’s inability to identify foreign invaders and
eliminate toxic substances and have an even higher risk of developing the
disorder if they’re vitamin D deficient.

Vitamin D protects against DNA damage and
can help repair damage once it’s occurred. (Its role in reducing damage in the
case of environmental toxins is being investigated.) In addi­tion, vitamin D
may reduce oxidative stress, a hallmark of ASD, and lower the number of
inflammatory cytokines present in the brain, which have been associated with
the disorder.

According to John J. Cannell, MD, founder
and execu­tive director of the Vitamin D Council, the prevalence of ASD
increases in “regions of greater cloud cover and rainfall.” Studies have shown
there are more ASD cases in children born between October and March. Research
suggests this may be due to the lack of sunlight exposure.

The body produces vitamin D when the skin
is exposed to the sun’s ultraviolet B rays, but during the cooler months of the
year, the sun isn’t out long enough for pregnant mothers to get ample exposure.
Ensuring women get adequate amounts of vitamin D during pregnancy is
imperative. In supplement form, the Recommended Dietary Allowance (RDA) is 600
IU. How­ever, if blood work shows a pregnant woman is deficient, a plan for
increasing her vitamin D level must be directed by her phy­sician, who may
prescribe doses much greater than the RDA. This applies to nursing mothers and
children with ASD as well.

Vitamin B6 and Magnesium

Vitamin B6 and magnesium supplementation
also are used in treating ASD patients. One way to boost intake is in the form
of a multivitamin that contains both at US Reference Daily Intake standards.
Some studies have shown improvements in behav­iors, such as increased speech,
decreased aggression/temper issues, better eye contact, increases in IQ, and
the ability to interact socially, with vitamin B6 and magnesium supplemen­tation.35
Other studies, however, have shown that high-dose pyridoxine supplements can
cause peripheral or sensory neu­ropathies, and larger doses of magnesium can
cause gas­trointestinal upset and diarrhea.

Other Supplements

Glutathione, which can be used in ASD
treatment, enables the body to detoxify and protect itself against oxidative
damage. Moreover, dimethyl glycine is touted to improve lan­guage skills and
the ability to make eye contact. However, there’s little evidence showing that
either alleviates symp­toms. More research is needed to show efficacy of some
of the current supplements being used.

Probiotics,
Antifungals, and Digestive Enzymes

Probiotics and antifungals are common
treatments for the abdominal pain, bloating, gas, constipation, gastro
esophageal reflux disease, nausea, vomiting, and diarrhea that many ASD
patients experience. No conclusive evidence is available to explain why these
digestive symptoms are common in ASD patients, but the use of probiotics has
provided relief of these symptoms for many of them.

The National Center for Complementary and
Alternative Medicine defines probiotics as live microorganisms—usually
bacteria, but they also can include microbes such as yeast—that people can
ingest to increase the population of desirable bacteria in the gut. Antifungals
inhibit the growth of a fungus or destroy it. They’re used in the treatment of Candida
albicans, a fungus frequently reported as the culprit when a yeast infec­tion
is present. It can cause itching and burning of the mucous membranes, skin
eruptions, and imbalances in the overall health of the gastrointestinal tract.

Digestive enzymes are substances that help break down
large macromolecules in foods to smaller substances to facilitate their
absorption. Examples of digestive enzymes include proteases that break down
proteins or lipases that help break down fat. If a dietitian suspects a patient
is experiencing inadequate digestion, digestive enzymes may help. In some
cases, digestive enzymes may aid in the removal of toxic compounds from the
gut.

Elimination Diet
Therapy

The elimination diet is another option
that has shown prom­ise in treating ASD and involves removing certain foods
from the diet for a period of time to determine whether they’re caus­ing
symptoms of food allergies and intolerances. Research has shown that
eliminating gluten and casein from the diet of ASD patients can alleviate
symptoms such as behavior problems and poor cognitive and social functioning.

There are several theories as to why the elimination
diet may be beneficial. One hypothesis is that ASD patients can’t digest gluten
and casein, causing the formation of the peptides gluteo­morphin and
caseomorphin and their absorption into the blood­stream because of increased
gut permeability, or leaky gut syndrome. These two peptides, which appear to
have a chemi­cal structure similar to opiates, can cross the blood-brain bar­rier
and cause symptoms such as delayed social and language skills, and withdrawn
behavior.

The elimination diet is another option
that has shown promise in treating ASD and involves removing certain foods from
the diet for a period of time to determine whether they’re causing symptoms of
food allergies and intolerances.

There are concerns about the use of a
gluten-free/casein-free diet because its planning requires a skilled
professional who understands the complexities of elimination diets and the
restrictions of appropriate foods. The exclusion of wheat and milk puts an ASD
patient at risk of nutrient deficiencies in cal­cium, protein, vitamin D, folic
acid, and B vitamins. And studies have found that diets lacking gluten and casein
raise the risk of decreased bone density and stunted growth. However, RDs can
introduce other foods into the diet as well as provide advice on nutritional
supplements to compensate for low nutrient intakes.

A more complex elimination diet that some specially
trained dietitians use is called the LEAP (Lifestyle, Eating, and Per­formance)
protocol. This involves eliminating any known foods or chemicals suspected of
triggering symptoms. These foods and chemicals are identified by a blood test
called the Medi­ator Release Test, which shows reactions to multiple foods and
chemicals. These reactions involve the immune systems of patients who ingest
foods and chemicals to which they’re sensitive. Their immune system identifies
these foods and chemicals as foreign invaders, causing the immune system to
release mediators to fight off the “invaders.”

Some of the mediators released include
histamine, prosta­glandins, leukotreines, cytokines, and peroxides. These media­tors
have been shown to cause reactions such as inflammation, diarrhea, pain,
intestinal cramping, constipation, headache, and pain receptor changes. Studies
have shown enhanced proinflam­matory cytokine production is present in patients
with ASD.

Reactions to certain foods and chemicals
also can cause the release of the brain neurotransmitters dopamine and sero­tonin.
Dopamine appeals to the sense of reward and enjoyment, and plays a role in
addictive behavior. Serotonin contributes to feelings of well-being and
happiness.

When dopamine and serotonin are released
as a result of ASD patients ingesting foods and chemicals to which they’re
sensitive, they may experience less pain, brain fog, or inabil­ity to focus and
concentrate. According to certified LEAP ther­apists, ASD patients also may
feel euphoric after ingesting a reactive substance or stop throwing a tantrum
after eating a reactive food. It’s in these instances where the Mediator
Release Test may help with identifying reactive substances that can be
eliminated to improve behavior, communication skills, and other immune-related
health issues and allow for more variety in the diet for better nutrition.

What Lies Ahead

So what does the future hold for
individuals with ASD? While there’s no concrete answer to this question, we
know RDs can play a huge role in the management and treatment of ASD symptoms.

RDs’ ability to analyze diets for
nutritional deficiencies can help concerned parents. Contacts with other
healthcare disci­plines that monitor patient behaviors make RDs invaluable as
they provide holistic approaches to treatment for optimal cogni­tive and social
functioning. RDs are the best source for provid­ing accurate and up-to-date
information on supplementation, elimination diet therapy, and current research
on new nutri­tional approaches.

More and more patients will depend on
dietitians as the source of information that will enable patients to live
productive lives. Dietitians with the passion to work with this challenging
segment of the population will be a much-needed resource in the dietetics
community in the years to come